Provider Demographics
NPI:1568687044
Name:BRUZEK, MARK JOHN (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOHN
Last Name:BRUZEK
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 AIR BASE ROAD
Mailing Address - Street 2:
Mailing Address - City:HERMANTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55811
Mailing Address - Country:US
Mailing Address - Phone:218-728-2117
Mailing Address - Fax:218-728-2700
Practice Address - Street 1:4419 AIR BASE ROAD
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811
Practice Address - Country:US
Practice Address - Phone:218-728-2117
Practice Address - Fax:218-728-2700
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34441223P0221X
MNS271223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33473800Medicaid
WI3444OtherDELTA DENTAL WI ID#